The Scientific Review of Mental Health Practice

Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work

THE SCIENTIFIC REVIEW OF MENTAL HEALTH PRACTICE

Our Raison dÊtre

Author:
Scott
O. Lilienfeld, Ph.D., is Editor in Chief of the Scientific
Review of Mental Health Practice. Correspondence concerning
this article may be sent to slilien@emory.edu.

Editor's
Note:
Portions of this article have been adapted from an invited
address delivered by the author at the 1998 American Psychological
Association Convention in San Francisco (see Lilienfeld, S.O.,
1998, Pseudoscience in clinical psychology, The Clinical
Psychologist, 51, 39). I thank Dr. Paul Rokke,
editor of The Clinical Psychologist, for granting me
permission to adapt some of the material from this address.

The
first question many readers of this article are likely to
ask is: Why another mental health journal? Indeed, this is
the very question with which I struggled for quite some time
before ultimately deciding that a new journal was not only
warranted, but necessary. But why add yet another title to
the already substantial and ever expanding list of journals
in psychology, psychiatry, social work, and related disciplines?
What unique contribution, if any, could another journal make
to the discipline of mental health practice?

My
modest goal in this article is to convince you that The
Scientific Review of Mental Health Practice fills a void
occupied by no other journal. In doing so, I also hope to
convince youif you have not already been convincedthat
the substantive issues to be addressed by this journal are
of pressing and even paramount importance to the manifold
fields of mental health practice.

WHATS
WRONG?

Over
the past several decades, the fields of clinical psychology,
psychiatry, and social work have borne witness to a widening
and deeply troubling gap between science and practice (see
Lilienfeld, 1998, for a discussion). Carol Tavris (1998) has
written eloquently of the increasing gulf between the academic
laboratory and the couch and of the worrisome discrepancy
between what we have learned about the psychology of memory;
hypnosis; suggestibility; clinical judgment and assessment;
and the causes, diagnosis, and treatment of mental disorders,
on the one hand, and routine clinical practice, on the other.
Less and less of what researchers do finds its way into the
consulting room, and less and less of what practitioners do
derives from scientific evidence. Researchers and practitioners
often spend disconcertingly little time communicating with
one another.

Bearing
out Tavriss contention is the marked upsurge in the
prevalence of unsubstantiated and in some cases demonstrably
ineffective or harmful techniques in clinical psychology,
psychiatry, and social work over the past few decades. The
information explosion of the late 20th and early 21st centuries
has become a misinformation explosion, and the dissemination
and promotion of untested and pseudoscientific mental health
techniques via the Internet, magazines, radio, and television
have accelerated at an unprecedented rate. Largely as a consequence,
the ratio of unscientific to scientific information in various
mental health domains has been steadily but perceptibly creeping
upward. Moreover, standards of research training in many disciplines,
including clinical psychology, have progressively dropped,
leading to a substantial increase in the proportion of individuals
with inadequate grounding in the basic scientific methodology
and critical thinking. Although the fields of mental health
are afflicted with numerous problems, problems in four major
areas appear to be particularly acute and pervasive.

Psychotherapy

A
wide variety of unvalidated and sometimes harmful psychotherapeutic
methods, including facilitated communication for infantile
autism (see Herbert, Sharp, & Gaudiano, this issue), suggestive
techniques for memory recovery (e.g., hypnotic age-regression,
guided imagery, body work), energy therapies (e.g., Thought
Field Therapy, Emotional Freedom Technique; see Media
Watch, this issue), and New Age therapies of seemingly
endless stripes (e.g., rebirthing, reparenting, past-life
regression, Primal Scream therapy, neurolinguistic programming,
alien abduction therapy, angel therapy) have either emerged
or maintained their popularity in recent decades. Moreover,
in a large-scale study published last year (Kessler et al.,
2001), individuals in the general population with a recent
history of anxiety attacks or severe depression were found
to avail themselves of complementary and alternative mental
health treatments (including energy healing and laughter therapy)
more often than conventional treatments. Thus, largely untested
treatments comprise a major proportionin some cases
a majorityof the interventions delivered by mental health
professionals.

According
to one recent conservative estimate (Eisner, 2000), there
are now between 400 and 500 different brands of psychotherapy,
and this number is increasing on a virtually weekly basis.
Even many of the most vocal critics of the present state of
clinical psychology (e.g., Dawes, 1994) acknowledge that psychotherapy
can be helpful in many instances. Yet because most flavors
of psychotherapy have not been subjected to rigorous empirical
evaluation (e.g., randomized, controlled trials), in the majority
of cases we have no way of knowing whether such treatments
are effective, ineffective, or harmful.

Assessment
and Prediction

Many
psychologists continue to use assessment techniques (e.g.,
the Rorschach Inkblot Test, human figure drawings, and other
projective methods; the Myers-Briggs Type Indicator) of doubtful
validity, and to draw inappropriate inferences on the basis
of well-validated tests. Computer-based test interpretations
(CBTIs) of psychological tests multiply on a yearly basis
even though most CBTI programs have never been subjected to
careful empirical scrutiny.

Moreover,
many clinicians render highly confident clinical judgments
on the basis of methods (e.g., anatomically detailed dolls
for the assessment of child sexual abuse) whose validity remains
highly controversial from a scientific standpoint (see Hunsley,
Lee, & Wood, in press). And in many cases, clinicians proffer
expert testimony on crucial questions (e.g., child custody
disputes) for which mental health professionals have not been
shown capable of providing valid predictions or recommendations
(ODonohue & Bradley, 1999). Contributing to and perhaps
compounding these problems is the general propensity of most
clinicians to be overconfident in their predictions across
a variety of tasks (Smith & Dumont, 1997).

Self-Help
and Self-Enhancement Methods

A
burgeoning industry of self-help books, manuals, programs,
and tapes thrives with unabated vigor and intensity, despite
the absence in most cases of compelling or even suggestive
evidence for their efficacy. The most recent available estimate
(Rosen, 1993) places the number of self-help books appearing
each year at approximately 2,000, and there is good reason
to believe that this number is rising. Although some of these
books may be effective, others may be either useless or harmful
(see Rosen, 1987, for evidence that certain self-help programs
can produce adverse effects).

Closely
allied to self-help techniques are a bewildering array of
self-enhancement methods, such as speed-reading courses, sleep-assisted
learning techniques, subliminal audiotapes, and hemispheric
synchronization devices, most of which have not been shown
to be effective. In addition, herbal remedies abound for enhancing
memory or mood, even though many are of questionable or unknown
efficacy. Moreover, more and more citizens look to self-proclaimed
media experts or gurus for guidance
concerning everyday life problems. Radio and talk show therapists
increasingly dominate the airwaves and influence the publics
perception of mental health practice, despite the fact that
many offer advice that is not in keeping with the best available
psychological science (Heaton & Wilson, 1995).

Psychiatric
Diagnoses

The
past several decades have seen a virtual explosion in the
use of controversial and poorly studied psychiatric labels,
such as codependency, sexual addiction, road rage disorder,
infanticide syndrome, parental alienation syndrome, premenstrual
dysphoric disorder, and Munchausens syndrome (factitious
disorder) by proxy (see Mart, this issue). Although some of
these labels may ultimately be shown to be predictively useful,
many are of undemonstrated validity (McCann, Shindler, & Hammond,
in press). Nevertheless, such labels are commonly invoked
by mental health professionals as scientific explanations
of problematic behavior and are introduced by them into courts
of law with increasing frequency. In still other cases, there
are serious concerns that some psychiatric conditions (e.g.,
dissociative identity disorder, known formerly as multiple
personality disorder) are being substantially overdiagnosed
in certain settings.

As
both researchers and practicing therapists, it is incumbent
on us to remain open to all novel and untested claims regarding
clinical practice. It would be a serious mistake to cavalierly
dismiss any of these claims before adequate research is available.
This holds true even for claims that are superficially implausible
or even bizarre. At the same time, however, we must insist
on rigorous standards of evidence before accepting these claims,
as the unbridled use of unsubstantiated or even blatantly
pseudoscientific techniques can cause irreparable damage to
the public and to mental health professions at large.

It
is essential to recall that the onus of proof for the demonstration
of the validity or effectiveness of new practices falls squarely
on the shoulders of the proponents of these practices. The
onus does not fall on the shoulders of skeptics to demonstrate
that these practices are invalid or ineffective. In plain
language, it is up to the proponents of novel techniques to
show that these techniques work.

WHAT
HAVE WE BEEN DOING?

The
field of mental health has until recently shown surprisingly
little interest in doing much about the problem of questionable
science and pseudoscience that has long been festering in
our own backyards. Paul Meehls (1993) trenchant remarks,
although directed primarily toward clinical psychologists,
provide a much-needed warning for individuals in all mental
health professions:

It
is absurd, as well as arrogant, to pretend that acquiring
a Ph.D. somehow immunizes me from the errors of sampling,
perception, recording, retention, retrieval, and inference
to which the human mind is suspect. In earlier times, all
introductory pschology courses devoted a lecture or two
to the classic studies in the psychology of testimony, and
one mark of a psychologist was hard-nosed skepticism about
folk beliefs. It seems that quite a few clinical psychologists
never got exposed to this basic feature of critical thinking.
My teachers at [the University of] Minnesota . . . shared
what Bertrand Russell called the dominant passion of the
true scientistthe passion not to be fooled and not
to fool anybody else . . . all of them asked the two searching
questions of positivism: What do you mean? How
do you know? If we clinicians lose that passion and
forget those questions, we are little more than be-doctored,
well-paid soothsayers. I see disturbing signs that this
is happening and I predict that, if we do not clean up our
clinical act and provide our students with role models of
scientific thinking, outsiders will do it for us. (pp. 728729)

Nor
has the American Psychological Association (APA), the worlds
largest organization of social scientists and the primary
home for both practicing and research psychologists, done
much to combat the increasing spread of questionable or pseudoscientific
mental health techniques. In fact, some critics might justifiably
contend that the APA has actually nurtured or provided support
for such techniques (Lilienfeld, 1998). Even a casual perusal
of recent editions of the APA Monitor on Psychology,
an in-house publication of the APA that is sent to all of
its members, reveals that the APA has been accepting advertisements
for a plethora of unvalidated psychological treatments, including
Thought Field Therapy and Imago Relationship Therapy, two
techniques for which essentially no published controlled research
exists. Among the recent workshops for which the APA has provided
continuing education (CE) credits to practicing clinicians
are courses in calligraphy therapy, neurotherapy (see Kline,
Brann, & Loney, this issue), Jungian sandplay therapy, and
the use of psychological theatre to catalyze critical
consciousness (see Lilienfeld, 1998). The APA has also
recently offered CE credits for critical incident stress debriefing,
a technique that has been shown to be harmful in several controlled
studies (Lohr, Hooke, Gist, & Tolin, in press). Moreover,
the APA has been exceedingly reluctant to impose ethical limitations
or sanctions on members who engage in either unvalidated or
potentially harmful mental health practices, including the
use of highly suggestive therapeutic techniques to recover
traumatic childhood memories.

Nevertheless,
there are at last indications that things are slowly beginning
to change. The 1999 Annual Convention of the American Psychological
Society featured a Presidential Symposium (chaired by Dr.
Elizabeth Loftus of the University of Washington) devoted
exclusively to the issue of pseudoscience in psychology. This
symposium, which was presented to a standing-room audience
of several hundred psychologists, attests to the growing interest
in the problems posed by pseudoscientific and fringe-science
claims in contemporary psychology. Two years ago, a new special-interest
group devoted to the study of pseudoscience within clinical
psychology (called Science and Pseudoscience Review)
was formed within the Association for Advancement of Behavior
Therapy (see www.pseudoscience.org). Even more recently, the
Committee for the Scientific Investigation of Claims of the
Paranormal (the group that publishes Skeptical Inquirer
magazine) established a new subcommittee dedicated to evaluating
the validity of questionable or untested mental health claims.

The
past several years has also witnessed a groundswell of interest
among physicians, including psychiatrists, in the impartial
investigation of claims in alternative and complementary medicine.
Prometheus Books, which publishes this journal, founded The
Scientific Review of Alternative Medicine (SRAM) to critically
examine such claims and to better educate practitioners concerning
the scientific status of practices on the fringes of current
medical knowledge. We very much hope that our journal will
make a worthy sibling to SRAM.

More
broadly, the fields of clinical psychology, psychiatry, and
social work have recently placed increased emphasis on evidence-based
mental health practices. Much of this interest has focused
on identifying psychological and pharmacological treatments
that are efficacious for specific disorders. Division 12 (Society
for Clinical Psychology) of the APA has generated a widely
disseminated list of empirically supported treatments (ESTs)
for both adult and childhood/adolescent disorders (see Chambless
& Ollendick, 2001, for a recent review; see also Hunsley &
Giulio, this issue), and this list has already begun to influence
clinical practice, education, and training. Although vigorous
and constructive debate surrounds the criteria established
for identifying ESTs, as well as the current list of ESTs,
there is a growing consensus among scientifically oriented
psychologists that the movement toward ESTs is both healthy
and essential for preserving the scientific foundations of
clinical psychology and allied fields. Calls for comparable
criteria and lists of empirically supported assessment techniques
to guide clinical practice (e.g., see Lilienfeld, Wood, &
Garb, 2000) are being heard in many quarters.

Despite
the increasing interest in and awareness of the problem of
pseudoscience and fringe science in the applied behavioral
sciences, no academic journal is devoted to the impartial
scientific investigation of novel, controversial, or untested
claims in mental health. As a consequence, a major void exists
among scholarly publications. Moreover, manuscripts dealing
with such claims are published in a wide variety of disparate
academic journals scattered across several subdisciplines,
including clinical psychology, cognitive psychology, social
psychology, counseling, psychiatry, psychiatric nursing, social
work, law, and educational psychology. Simply put, such manuscripts
have no home. Researchers and practitioners who wish to keep
abreast of the status of mental health claims on the fringes
of scientific knowledge are therefore severely handicapped.

OUR
RAISON DÊTRE

So
why should we be concerned about the widening gap between
mental health science and practice? We can identify at least
four major reasons, which collectively serve as the raison
dêtre for this new journal.

(1)
Unvalidated or scientifically unsupported mental health practices
undermine the general publics confidence in our professions.
Once the reputation of the mental health professions has been
sullied, many individuals in the general public may understandably
be reluctant or unwilling to seek psychological or psychiatric
treatments, a number of which may be effective. In addition,
after seeing mental health professionals make unwarranted
or dubious assertions, many individuals in the general public
may accord less weight to psychological advice derived from
well-supported research findings.

(2)
Unvalidated or scientifically unsupported mental health practices
can lead individuals to forgo effective treatments. Economists
refer to this unfortunate consequence as opportunity
cost. Many individuals who spend large amounts of time
and money on ineffective treatments may be left with precious
little of either. As a result, they may forfeit the opportunity
to obtain treatments that could be more helpful. Thus, even
ineffective treatments that are by themselves innocuous can
indirectly produce negative consequences.

(3)
Unvalidated or scientifically unsupported mental health practices
can be harmful. In the field of psychotherapy, the default
assumption has often been that doing something is better
than doing nothing. Although this assumption may well
hold true in certain cases, it has been shown to be demonstrably
false in others. The growing literature on deterioration
effects in psychotherapy increasingly suggests that
a thankfully small but nevertheless nontrivial proportion
of individuals (perhaps 3 to 6%) tend to become worse following
treatment (Strupp, Hadley, & Gomez-Schwartz, 1978), although
the variables that account for such deterioration remain controversial.
Moreover, therapists who use highly suggestive techniques,
such as hypnosis, guided imagery, and sodium amytal (the so-called
truth serum), to recover purported memories of satanic ritual
abuse and alien abductions may be inadvertently inducing analogues
or even full-blown variants of posttraumatic stress disorder
in their clients (Chu, 1998). The tragic and heartbreaking
case of Candace Newmaker, the 10-year-old Colorado girl who
was smothered to death in 2000 by therapists practicing rebirthing
therapy, an unvalidated technique for treating children with
attachment problems, attests to the dangers of implementing
methods that are empirically unsupported, untested, or both.
Still other techniques, such as facilitated communication
for infantile autism (see Herbert, Sharp, & Gaudiano, this
issue), have resulted in falseand in some cases terribly
destructiveaccusations of child abuse against family
members.

(4)
Unvalidated or scientifically unsupported mental health practices
eat away at the scientific foundations of our professions.
Richard McFall (1991) has argued persuasively that the scientific
basis of clinical psychology is steadily eroding as a consequence
of this professions collective failure to attend to
the threats posed by unsubstantiated treatment and assessment
methods. Once we abdicate our responsibility to uphold high
scientific standards in administering treatments, our scientific
credibility and influence are badly damaged. Moreover, by
continuing to ignore the imminent dangers posed by questionable
mental health techniques, we send an implicit message to our
students that we are not deeply committed to anchoring our
discipline in scientific evidence or to combating potentially
unscientific practices. Our students will most likely follow
in our footsteps and continue to turn a blind eye to the widening
gap between scientist and practitioner, and between research
evidence and clinical work.

WHAT
AND WHO WE ARE

With
these four major reasons in mind, we are proud to announce
the launch of a new peer-reviewed journal, The Scientific
Review of Mental Health Practice:Objective Investigations
of Controversial and Unorthodox Claims in Clinical Psychology,
Psychiatry, and Social Work. The primary goal of this
interdisciplinary journal is to assist researchers and practitioners
across all of the major subdisciplines of mental health with
the crucial task of distinguishing scientifically supported
from scientifically unsupported claims. In doing so, we intend
to provide professionals with a usefulif not indispensabletool
for sorting out the wheat from the often considerable chaff
in the mental health field. We also believe that this journal
will prove to be of considerable interest to individuals in
a variety of disciplines closely allied with mental health,
including education, law, philosophy, and nursing, many of
whom require a trustworthy source for au courant scientific
information regarding mental health practices.

In
evaluating mental health claims, we pledge to subject all
claims to careful and searching scrutiny but not to dismiss
any of them out of hand. Indeed, our hope is that at least
some of the novel and largely untested techniques we place
under the empirical microscope will ultimately stand the test
of time. Others likely will not. In either case, we believe
that the careful scientific scrutiny accorded to these techniques
will prove to be beneficial to the continued health of the
discipline of mental health practice.

In
addition to providing a forum for presenting the best available
scientific evidence on the fringes of current knowledge in
mental health, we intend to enhance the overall quality of
discourse regarding controversial issues in the behavioral
sciences. By raising the bar for the level of
scientific debate on such issues, we hope to facilitate improved
research and thinking about critical questions on the fringes
of present scientific knowledge concerning mental health.

The
Scientific Review of Mental Health Practice has been established
with the generous support and encouragement of Dr. Paul Kurtz
and Steven Mitchell of Prometheus Books, both of whom have
expressed an unwavering commitment to enhancing the level
of critical thinking in mental health and related domains.
With their help, we have assembled an outstanding and internationally
recognized group of approximately 70 scholars across the worldincluding
experts in psychology, psychiatry, social work, philosophy,
and lawto comprise our Council for Scientific Mental
Health Practice, the umbrella group that has endorsed the
journal and its mission. In addition, we have formed an elite
editorial board of outstanding researchers and practitioners
drawn from several mental health subdisciplines. Our three
associate editors, Dr. James Herbert of MCP Hahnemann University,
Dr. John Kline of Florida State University, and Dr. Timothy
Moore of Glendon College (York University), have distinguished
themselves as both first-rate scholars and as individuals
deeply committed to fostering the integration of science and
clinical practice.

We
very much hope that you will enjoy this first issue of The
Scientific Review of Mental Health Practice and that you
will provide us with your constructive feedback and suggestions
as the journal continues to evolve and take shape. Indeed,
we sincerely hope that you and other readers will hold us
to the same high standards we hold for the field of mental
health practice. We look forward to hearing from you.